HIV/AIDS and STI Prevention and Control Project in Bhutan

Executive Summary

The HIV incidence in Bhutan has seen increasing over last decade ever since the first detection of HIV case in the year 1993. Since then, HIV was given the due attention with the establishment of the National STI and HIV/AIDS Control Programme in 1988, even before the first case of HIV was detected. This rise has been attributable to increasing prevalence of Sexually Transmitted Infections, strengthened HIV detection services with improved infrastructures and nevertheless the improved public awareness on the importance of getting oneself tested. Until July 2011, we have 246 total HIV cases throughout the country.

The implementing agency of this project was Ministry of Health where main objectives was to determine the geographical spread of HIV infection, monitor the trend of HIV epidemic in the country, provide information for estimates and future projections of HIV/AIDS in the country and to provide useful data for planning and implementation of HIV/AIDS prevention and control program activities with the total budget of US$ 5.94 million funded by world bank and non-world bank. The motive behind implementing this project was to reduce the risk of HIV and STI transmission among the general population, in particular among groups with high risk sexual behaviors.

The project consists of four components, each one having their own budget allocation and aims. More over project management framework, log frame, key stakeholder and their expectation has been discussed. Finally in conclusion it talks about weak integration of STI and HIV/AIDS services and institutional coordination and staffing issues during implementation leading to the unsatisfactory outcome of the project.

Introduction

Over the past 30 years HIV infection has been one of the most chronic diseases which have infected our society. The disease has claimed million of lives around the world. It is a global deadly disease with over 37 million people estimated to be infected across the globe, not leaving even the most isolated country like Bhutan. The country has remained isolated from the outside world until 1960s. However Bhutan has slowly started opening its doors to the outside world after it became a member of the United Nations in the year 1971.

The first case of HIV infection in Bhutan was detected in 1993. Since then, the number of cases has been on rise year after year. While the number of reported cases seems small compared to other countries in the region with very high burden of infection, it is still of public health concern given the small size of its population. Its two immediate neighbors are China, with an estimated 0.7 million people living with HIV (PLHIVs), and India with which Bhutan shares an open border with over 2.1 million PLHIVs. Therefore, HIV was given the due attention with the establishment of the National STI and HIV/AIDS Control Programme in 1988, even before the first case of HIV was detected within its border (Tshering, Lhazeen, Wangdi & Tshering, 2016).

Bhutan, though isolated geographically is not impervious to HIV. However increasing numbers in cross-broader movement and international travel combined with behavioral risk factors such as unprotected sex, injection drug use (IDU) and men having sex with men makes Bhutan much more exposed to the spread of HIV. According to the UNAIDS estimates, Bhutan is low HIV prevalence country with an estimated HIV of 0.2% among adult aged 15-45 years in 2012. The HIV prevalence among male and female aged 15-24 was 0.1% for both sex. Furthermore, the 2013’s Annual Health Bulletin of the Ministry of Health in Bhutan revealed an increase of HIV cases detected from 38 in 2000 to 297 in 2012. Almost 90% of these HIV infections were attributed to unsafe sexual practices (World Bank, 2011)

Problem identification

At the time of assessment, only 45 cases of HIV had been detected in Bhutan, but there were rising concerns over the increasing number of new infections detected every year. The maximum of new infections were acquired through unprotected sex, with the main behavioral factor being non-paid casual sex among long-distance drivers, members of the armed forces, migrant workers, and drug users. And also one of reason is due to high mobility across the borders (Half of the reported cases were from Thimphu and Phuentsholing which are on the border with India).

The inclusion of groups engaging in risk behaviors in the statement of the project’s objective was therefore highly relevant. The estimated number of STIs in the country was significantly higher than the number of HIV /AIDS cases, which another factor is contributing to HIV exposure in Bhutan (Tshering, Lhazeen, Wangdi & Tshering, 2016). Therefore, even though Bhutan has low HIV prevalence the challenge for the country is to continue this low prevalence with the occurrence of modernization and globalization.

This component has supported in:

• i) Improving access to and use of condoms through condom social marketing and strengthening logistics and information systems to ensure timely distribution of condoms in public health facilities, and to all implementing agencies including NGOs
• ii) Elevating political and societal leadership and commitment to HIV/AIDS and STI prevention and control through advocacy
• iii) Increasing knowledge about HIV/AIDS and STIs and positive attitudes toward prevention and safer sexual behaviors among the general public through mass media and targeted interventions specifically designed to reach the local populations in addition to training of village health workers, traditional healers, and public health staff, and innovative initiatives to be undertaken by other sectors
• iv) Promoting behaviors that reduce the risk for HIV infection among priority groups through peer education, innovative outreach and communications strategies, and provision of voluntary counseling and testing, and STI treatment. In addition to priority subpopulations including the armed forces, mobile populations (drivers), sex workers and out-of-school youth

Component 2 – Institutional Strengthening and Building Capacity has supported in:

• (i) strengthening laboratory services by instituting a national quality assertion for all laboratories, establishing an information system, ensuring sufficient equipment and reagents, and training technicians to ensure improvement in HIV and STI diagnostics and treatment
• ii) Improving blood transfusion services through policy development, training of technicians and health workers, and campaigns to increase clinical and safe use of blood and blood products and voluntary donation
• iii) Enhancing management, technical, and implementation capacity of the National AIDS Control Program, and implementing agencies and strategic planning through formulation of a National Policy on HIV/AIDS, local and foreign training, and technical assistance.

Component 3 – Care, Support and Treatment of AIDS and STIs has supported in:

• (i) Increasing access and use of voluntary counseling and testing (VCT) services through establishment of five VCT centers in key areas and facilities, training of counselors, outreach services for difficult to reach populations, and demand generation for VCT services.
• (ii) strengthening management of AIDS and Opportunistic Infections and establishing care and support for people living with HIV/AIDS (PLWHA) through development of national treatment guidelines for a comprehensive care and support approach, including anti-retroviral treatment as indicated; establishing and training district level clinical teams; improving laboratory support; instituting a drug information systems; and innovative grants or subprojects to involve PLWHA.
• (iii) Improving management of STIs through routine screening of ANC syphilis at district and army hospitals, updating existing STI syndromic management guidelines, improving syndromic treatment of STIs including antibiotic susceptibility studies, widespread dissemination of updated treatment guidelines to pharmacies and health facilities, and training of health care providers.
• (iv) Reinforcing waste management and infection control through training of health personnel, monitoring, and procurement of equipment and supplies (a national waste management plan was developed during project preparation).

Component 4: Strategic Information for HIV/AIDS and STI has supported in:

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• (i) Enhancing management information systems and use of information technology to promote evidence based decision making and strategic planning through development of IT infrastructure and training on management and use of data.
• (ii) Strengthening operational research capacity, especially to carry out social and behavioral research through training
• (iii) Establishing second generation surveillance and monitoring and evaluation systems, which include conducting assessments, population survey and special studies, obtaining technical assistance, and providing foreign training. (World Bank, 2004)

With an objective of this project, a team has established to provide management and administrative support to the implementing agencies by testing acceptability and feasibility of the project. Stakeholders, program implementers and health care providers were in agreement with the need of IBBS survey. And one of the participants reported a high level of trust in MOH resulting in their willingness in participating in the project. Therefore, PMT has the following role and responsibilities:

• (i) coordinate and manage implementation of project activities (e.g., MOH departments and divisions, other sectors, Dzonghkags, MSTFs, and NGOs);
• (ii) regularly supervise, monitor, evaluate, and report on project activities to the relevant government agencies and to the Bank;
• (iii) oversee financial management and procurement of goods, civil works, and consultancies; and
• (iv) Interact with the Bank on a regular basis on all project-related activities, including planning and preparation of missions. Technical Committee: The Technical Committee would ensure that preparation and implementation by NACP, PMT staff and consultants is in conformity with the objectives of the project and is carried out according to the terms of reference for specific components/activities.

The Technical Committee will be chaired by the Director of the Department of Public Health and would comprise PMT staff, NACP program manager, component coordinators, and representatives of relevant institutions and programs. This Committee would also provide an entry point for input from donor agencies. Responsibilities of this committee include:

• (i) ensure coordination between the project, MoH, the health authorities and other public entities;
• (ii) coordinate the activities of different donors in order to increase the efficient use of resources;
• (iii) approve work-plans submitted by public institutions;
• (iv) approve subprojects submitted by NGOs and other civil society organization;
• (v) ensure that the Project Operational Manual (OM) are developed and maintained updated;
• (vi) ensure that the hiring of the Technical Assistance and all training activities are timely prepared and organized and will also ensure that communications and coordination and reporting links with the related stakeholders are established and well conducted;
• (vii) Coordinate Bank and other Donors’ supervision missions, and carry out the mid-term review of the project;
• (viii) Ensure that implementation is in consistency with the objectives of the project and is carried out according to the terms of reference for specific objectives/ activities.

Implementation mechanisms- The project would employ three types of implementation mechanisms: work plan, subprojects, and contracts. The type of implementing agency and type of intervention would determine the mechanisms.

i) Work plan

Prepare an annual work plan for project activities, following the existing annual planning mechanism and according to the cycle and criteria established in the OM. Funds would be disbursed based on utilization certificate and results achieved.

ii) Subprojects

NGOs and private institutions would be eligible based on selection criteria, would develop a proposal and financing plan for a subproject, and upon approval of the proposal by PMT and the Technical Committee, including NACP, the implementation agency (IA) would sign a legal agreement with the Project Coordinator and funds would be disbursed based on utilization certificate and reporting on progress and results.

iii) Contracting

Implementing Agency (e.g., suppliers, contractors, private sector,MOH) would be recruited and hired based on IDA Guidelines and Standard Bidding Documents and, upon selection, IA would sign a contract with the Project Coordinator. Payment would then be released upon meeting the specified indicators and deliverables (World Bank, n.d)

M&E implementation was a challenge for the project till end. Schedule data associated to project activities were not collected systematically. There were no standard reporting formats or reporting schedule for implementers to report project activities back to the Project Management Team (PMT). There was no information system in the PMT to keep track of project activities either. In 2005, the project team added 20 new process indicators for the purpose of activity monitoring, although such indicators were not processed formally to be part of the official Results Framework. While the project could benefit from additional process indicators, the number of such indicators was extreme and formed an extra burden on the implementing agency which failed to monitor them in a systematic manner.

Consequently, it fell on the Bank to take the lead in coordinating M&E and data collection during each mission. The project made little headway in introducing a culture of information-based planning and decision making. For example, the results of surveys implemented under the project were not widely circulated to all implementers as inputs for their work plans. It was only toward the end of the project that a factsheet was set by the MOH to provide information on key survey findings. Although a large number of program officers, managers and health workers (641 in total) were trained in the use of data for management, routine M&E data were not used for providing feedback to implementers for supervision purposes. So only the following were carried out: -

• One round of the HIV/AIDS General Population Survey (GPS) in 2006;
• One round of HIV/AIDS Behavioral Surveillance Survey (BSS) for high risk groups in 2008;
• The first round of the Health Facility Survey (HFS) in 2009; and
• The second round of the HFS for a subset of facilities in 2011.

A rapid assessment on sexual networks was conducted in Thimphu (2010) and Phuntsholing (2011) and demonstration study on the risk factors of HIV/AIDS infections in Bhutan was also carried out in 2011. All the surveys were implemented late in the project cycle, so they could not serve as start-of-project baselines. Some key project indicators could have been monitored by the surveys, but they were not included in the survey instruments. However, the surveys have appreciably improved the information base on HIV/AIDS in Bhutan so far as they have established baseline data for Bhutan for the first time. They also provided useful inputs for the development of the 2012-2016 National HIV/AIDS Strategic Plan in Bhutan (World Bank, 2011).

Conclusion and observations

The main aim of this article was to study the profile of HIV in Bhutan as well as to describe the progress made. Based on the available data we can conclude that the country has a low HIV prevalence. A timely intervention by the Government and its partners has ensured the persistence of this low prevalence over the last two decades.

However, the increasing number of cases being detected remains a cause for concern. Major HIV epidemics often transition from an initial low prevalence with a slow growth. Existing risk factors such as high STI rates, multiple sexual partners and increasing number of cross border movements can fuel a large HIV epidemic. Furthermore, the limited data and information available, especially among key populations at risk of acquiring HIV infection, is a major limitation. Building evidence would be the key to inform the future strategic direction of the national response. Efforts to gather and use data to advocate, mobilize resources and design evidence-based programmes relevant to the country‘s specific needs and epidemiological pattern are of crucial importance to attempt to maintain the present low HIV prevalence status of the country.

Despite a slow start, project was on track until mid 2007. An evaluation was conducted in November 2006 which did not identify major issues other than the need to strengthen M&E. From early 2008 to closing, the project became a problem project at several points in time. Although there was no formal project change or restructuring, the work plan was significantly modified in 2009 to avoid duplication with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) activities. As the result, most of the multi-sectoral activities were no longer supported by the project. So the overall rating of the project is unsatisfactory due to weak integration of STI and HIV/AIDS services and institutional coordination and staffing issues during implementation.

References

1. Ministry of Health, (2009). Technical Strategy for Prevention and Control of sexually Transmitted Infections. Thimphu: Bhutan
2. Tshering, P., Lhazeen, K., Wangdi, S., & Tshering, N. (2016). Twenty-two years of HIV infection in Bhutan: epidemiological profile. Journal of Virus Eradication, 2, 45-48.
3. World Bank, (2011). Implementation Completion and Result Report For HIV/AIDS and STI Prevention and Control Project. Retrieved from http://www.documents.worldbank.org
4. World Bank, (2004). Project Appraisal Document For An HIV/AIDS And STI Prevention And Control Project. Retrieved from http://www.worldbank.org/infoshop
5. World Bank, (n.d). Project Information Document (PID) Appraisal Stage. Retrieved from http://www.documents.worldbank.org